TOPIC- ASSESSMENT, HISTORY TAKING, PHYSICAL

EXAMINATION AND INVESTIGATIONS RELATED TO EYE

DISORDERS
UNIT- MANAGEMENT OF PATIENTS WITH DISORDERS OF
EYE AND ENT
SUBJECT-MEDICAL SURGICAL NURSING

DATE OF SUBMISSION:
DATE OF PRESENTATION:

TABLE OF CONTENT

S.NO. TOPIC PAGE NO.

1. Introduction

2. Anatomy and physiology of eyes

3. History
 Bio demographical data
 Current health
 Review of systems

4. Physical examination
 External eye
 Internal eye/diagnostic evaluation

5. Research articles
6. Summary and conclusion

7. References
 ASSESSMENT, HISTORY TAKING, PHYSICAL EXAMINATION AND
INVESTIGATIONS RELATED TO EYE DISORDERS
INTRODUCTION
The eye is a unique organ because its external anatomy can be assessed easily. Internal eye
structures, including blood vessels and central nervous system tissue (retina and optic nerve)
are also easily visualised through cornea without invasive procedures. The effects of many
systemic problems, such as infections, cancer, vascular disorders and autoimmune disorders,
can be detected during an internal eye examination. Clients may voice misconceptions about
vision and the eyes.
ANATOMY AND PHYSIOLOGY OF EYES
Unlike most organs of the body, the eye is available for external examination, and its
anatomy is more easily assessed than many other body parts. The eyeball, or globe, sits in a
protective bony structure known as the orbit. Lined with muscle and connective and adipose
tissues, the orbit is about 4 cm high, wide, and deep, and it is shaped roughly like a four-sided
pyramid, surrounded on three sides by the sinuses: ethmoid (medially), frontal (superiorly),
and maxillary (inferiorly). The optic nerve and the ophthalmic artery enter the orbit at its
apex through the optic foramen. The eyeball is moved though all fields of gaze by the
extraocular muscles. The four rectus muscles and two oblique muscles are innervated by
cranial nerves (CN) III, IV, and VI. Normally, the movements of the two eyes are
coordinated, and the brain perceives a single image.
The eyelids, composed of thin elastic skin that covers striated and smooth muscles, protect
the anterior portion of the eye. The eyelids contain multiple glands, including sebaceous,
sweat, and accessory lacrimal glands, and they are lined with conjunctival material. The
conjunctiva, a mucous membrane, provides a barrier to the external environment and
nourishes the eye. The goblet cells of the conjunctiva secrete lubricating mucus. The sclera,
commonly known as the white of the eye, is a dense, fibrous structure that comprises the
posterior five sixths of the eye. The sclera helps to maintain the shape of the eyeball and
protects the intraocular contents from the cornea, a transparent, avascular, and domelike
structure, forms the most anterior portion of the eyeball and is the main refracting surface of
the eye. The choroid lies between the retina and the sclera. It is a vascular tissue, supplying
blood to the portion of the sensory retina closest to it.
Behind the cornea lies the anterior chamber, filled with a continually replenished supply of
clear aqueous humor, which nourishes the cornea. The aqueous humor is produced by the
ciliary body, and its production is related to the intraocular pressure (IOP). Normal pressure
is 10 to 21 mm Hg. The uvea consists of the iris, the ciliary body, and the choroid. The iris,
or colored part of the eye, is a highly vascularized, pigmented collection of fibers surrounding
the pupil. The pupil is a space that dilates and constricts in response to light.
Directly behind the pupil and iris lies the lens, a colorless and almost completely transparent,
biconvex structure held in position by zonular fibers. It is avascular and has no nerve or pain
fibers. The lens enables focusing for near vision and refocusing for distance vision. Posterior
to the lens is the vitreous humor. The innermost surface of the fundus is the retina. The retina
is composed of 10 microscopic layers and has the consistency of wet tissue paper. It is neural
tissue, an extension of the optic nerve. Viewed through the pupil, the landmarks of the retina
are the optic disc, the retinal vessels, and the macula. The point of entrance of the optic nerve
into the retina is the optic disc.
 Fig. Anatomy of eye
HISTORY
A complete ophthalmic history includes demographic data, exploration of chief complaint
and related manifestations, review of systems, past medical history, past surgical history,
allergies and medications, dietary habits, psychosocial history and lifestyle, and family health
history.
Biographical and demographic data-
 Patient's full name
 Age -The incidence of cataract, dry eye, retinal detachment, glaucoma, etc increase
with age.
 Birth date
 Gender- Hereditary color vision deficits are more common in men than in women.
 Address and contact telephone number
 Occupation.
Current health-
 Chief complaint- The most common chief complaint is a change or loss of vision.
The complaint may also be less specific, such as headache or eyestrain. Sometimes
the client may be unable to verbalize a specific complaint, and the chief complaint
could be as vague as “something is wrong with my eyes.”
 Clinical manifestations- Ocular manifestations can be divided into three basic
categories: (1) vision, (2) appearance and (3) sensations of pain and discomfort.
Whenever possible, characterize clinical manifestations according to onset, location,
duration and characteristics such as frequency and severity.
Pain (Ophthalmalgia)- Eye pain is often poorly localized. Nonspecific complaints
include eyestrain, pulling, pressure, fullness, or generalized headache. Pain may be
periocular, ocular, or retrobulbar (behind the globe).
Abnormal vision- Visual changes or loss of vision can be caused by abnormalities in
the eye or anywhere along the visual pathway. It may include refractive (focusing)
error; lid ptosis, clouding or interference in the cornea, lens, aqueous or vitreous
space; and malfunction of retina, optic nerve or intracranial visual pathway.
Abnormal appearance- Any growths, lesions, oedema, ptosis and abnormal position.
The most common abnormal appearance is a red eye.
Abnormal sensation- Reflex spasm of the ciliary muscle and iris sphincter that occurs
with inflammation may produce brow ache and photophobia or a constricted pupil.
Itching is usually a sign of an allergic response. Dryness, burning and mild foreign
body sensation can occur with dry eyes or mild corneal irritation.
Review of systems-
Many disease processes can affect vision. Vascular problems such as hypertension can
impact blood flow to the eyes, causing changes in vision. Headaches with visual changes may
indicate a tumour in the brain or be a cue to migraine. Review of system relevant to ocular
assessment includes asking about manifestations such as headaches and problems with
sinusitis.
Past medical history- The past medical history focuses on systemic disorders commonly
associated with ocular manifestations. Some of these illnesses, such as diabetes mellitus,
rheumatoid arthritis, and thyroid disorders may be recently acquired by adults or may have
occurred in the client’s childhood. Inquire about childhood vaccinations, particularly for
measles. Ask about hypertension, multiple sclerosis and myasthenia gravis. If the client wears
eyeglasses or contact lenses, ask when the last eye examination took place and when the
prescription was last changed. Hospitalizations related to the eyes or brain, including a
history of head or eye trauma, must be assessed.
Surgical history- It may include corrective vision surgery such as laser-assisted in-situ
keratomileusis (LASIK), radial keratotomy (RK), cataract removal, glaucoma treatment, or
eye muscle correction. Some eye surgeries, such as those for glaucoma, can precipitate other
eye issues (cataract). History of brain or facial surgeries should also be assessed as these have
the potential to affect vision.
Allergies- Note any allergies to medications (eye drops) and other substances such as
inhalants (dust, chemicals or pollens) and environmental contacts (cosmetics or pollens).
Allergic manifestations include eye redness, tearing and itching.
Medications- Many medications including prescription drugs, affect the eyes. Note the name,
dose, and frequency the medication is taken. Specifically ask about use of over-the-counter
eye drops, as those with antihistamines and decongestants can dry the ocular surface. Record
current eye and systemic medications being used, and all other current and past ocular
disorders.
Dietary habits- Inquire about the use of herbal remedies and dietary supplements (vitamins).
Some clients may consume large doses of vitamins, believing these substances will prevent
the development of vision problems such as cataract, and macular degeneration. Diets rich in
fruits, vegetables, and fish or supplements of antioxidants C, E and beta-carotene, have
potential to reduce the incidence of visual problems like macular degeneration. However,
many OTC preparations taken in too large a quantity can be harmful.
Social history- It includes occupational hazards, leisure activities and hobbies, and health
management behaviours. Assess the client’s work and/or hobbies that may include exposure
to irritating fumes, smoke, or air-borne particles. Assess participation in activities that
increase the risk for eye or head trauma (such as football, racquetball or baseball) as well as
those that increase the risk of foreign body injury or abrasion (e.g. hiking or gardening).
Address client use of protective eye gear (such as safety goggles or sunglasses) when
engaging in these activities.
Family health history – Many ocular disorders tend to be familial (strabismus, glaucoma,
myopia, hyperopia). Other conditions such as diabetes, retinoblastoma, retinitis pigmentosa,
and macular degeneration also tend to appear in families.
PHYSICAL EXAMINATION
Basic physical examination of eyes includes assessment of external structures via inspection
and palpation.
External eye

Fig. External eye and lacrimal apparatus.

 Eye position- Assess eye position for symmetry and alignment.
 Eyebrows- Inspect the eyebrows for symmetry, hair distribution, skin conditions and
movement. The eyebrows normally move up and down smoothly under the control of
the facial nerves.
 Eyelids and eyelashes- Examine the eyelids and eyelashes for placement and
symmetry. Normally, the sclerae are not visible above or below the irides when the
eyelids are open. Elevate the eyebrows to inspect the upper lids for lesions. Inspect
the lower lids by asking the client to open the eyes. Examine skin of the eyelids and
orbit by palpating for texture, firmness, mobility, and integrity of the underlying
tissues. Assess the blink response. Blinking is an involuntary reflex that occurs
bilaterally up to 20 times a minute.
 Eyeballs and lacrimal apparatus- To palpate the eyeballs, instruct the client to close
the eyes and look down. Place the tip of the index fingers on the upper eyelids, over
the sclerae, and palpate gently. Normally, the eyeballs feel firm and symmetrical.
Visualize the lacrimal apparatus by retracting the upper lid and having the client look
down. The area should be free of swelling, oedema and excessive moisture, and there
should be no regurgitation of fluid from sac or puncta.
 Conjunctiva and sclera- Inspect the conjunctiva and sclera for colour changes, texture,
vascularity, lesions, thickness, secretions, and foreign bodies. The bulbar conjunctiva
is colourless and transparent, allowing the sclera to be seen. Retract the lower eyelids
to expose the conjunctiva without applying pressure to the eyeballs. Gently push the
lower lids down against the bony orbit while the client looks up. Healthy conjunctivae
are pink to light red. If the lower palpebral conjunctivae are normal, the upper
palpebral conjunctivae usually are not inspected.
 Cornea and anterior chamber- Inspect the cornea and anterior chamber from an
oblique angle while shining a penlight on the corneal surface. The irides are easily
visible. In older adults, a thin, greyish white ring around the edge of the cornea (arcus
senilis) may be seen. The anterior chambers should appear clear and transparent with
no cloudiness or shadows cast on the irides. The depth of the chamber between the
cornea and iris is normally about 3 mm.

Fig. Arcus senilis

  Iris and pupil- Inspect the iris and the pupil with the same oblique lighting from the
penlight. The iris should light up and have a consistent color. The light should also
cause the iris to constrict as the optic nerves are stimulated, causing the pupil to
become smaller. Dim lighting causes the pupil to dilate. Pupils are normally black and
round, have smooth borders, and are equal in size. Inspect the pupils for size, equality,
shape, and ability to react to light and accommodation (PERRLA). Pupil
abnormalities may be caused by neurologic disease, intraocular inflammation, iris
adhesions, systemic or ocular medication side effects, or surgical alteration.

Fig. Normal physical assessment findings

Internal eye/ diagnostic evaluation
 Visual acuity testing- A visual acuity test is an eye exam that checks how well you see
the details of a letter or symbol from a specific distance. Two commonly used tests
are Snellen and random E.
The Snellen test uses a chart of letters or symbols. The letters are of different sizes
and arranged in rows and columns. Viewed from 14 to 20 feet away, this chart helps
determine how well we can see letters and shapes.
In the random E test, we identify the direction the letter “E” is facing. Looking at the
letter on a chart or projection, we have to point in the direction the letter is facing: up,
down, left, or right.
The Jaeger chart is an eye chart used in testing near vision acuity. It is a card on
which paragraphs of text are printed, with the text sizes increasing from 0.37 mm to
2.5 mm. This card is to be held by a patient at a fixed distance from the eye dependent
on the J size being read. The smallest print that the patient can read determines their
visual acuity.

Fig. Snellen chart

 Confrontation visual field testing – It involves having the patient looking directly at
your eye or nose and testing each quadrant in the patient's visual field by having them
count the number of fingers that you are showing. This is a test of one eye at a time.
It is useful for the examiner to close one eye so that one can determine if the patient is
seeing appropriately in their visual field.
 Extraocular muscle functions- The extraocular muscles are the six muscles that
control movement of the eye and one muscle that controls eyelid elevation (levator
palpebrae). The actions of the six muscles responsible for eye movement depend on
the position of the eye at the time of muscle contraction. The six muscles are the
lateral, medial, inferior and superior rectus muscles, and the inferior and superior
oblique muscles.

Fig. Muscles of eye

 Direct ophthalmoscopy- The direct ophthalmoscope uses a light source and reflective
mirrors to provide a magnified (*15) image of the fundus (posterior portion of the
eye) and a detailed view of the disc and retinal vascular bed. In a darkened room, the
instrument is held 1 to 2 inches away from the client’s eye for examination. Retinal
veins radiate from the disc and are darker, and slightly thicker, than arteries. The
retinal background is pink and choroidal vessels appear as linear orange streaks. The
presence of a cataract, or cloudy cornea, may impair examination.

The fundus is the only site in the body where the vascular bed may be observed
directly. Abnormal findings include an altered arteriovenous ratio, narrowed arteries,
widened veins, pinched-off vessels, abnormal arterial light reflex, excessive
tortuosity, numerous arteriovenous nicks, exudates, white patches and focus
haemorrhage.
Direct ophthalmoscope is one that produces an upright, or unreversed, image of
approximately 15 times magnification.

Fig. Direct ophthalmoscopy

 Indirect Ophthalmoscopy-Indirect ophthalmoscopy is one that produces an inverted,

or reversed, image of 2 to 5 times magnification. It employs a head lamp device to
shine a very bright light into the eye. An indirect ophthalmoscope, constitutes a light
attached to a headband, in addition to a small handheld lens. It provides a wider view
of the inside of the eye. Furthermore, it allows a better view of the fundus of the eye,
even if the lens is clouded by cataracts.
 Fig. Indirect ophthalmoscopy

 Slit-lamp examination-The slit lamp exam is a standard diagnostic procedure, which

is also known as bio microscopy. A slit lamp combines a microscope with a very
bright light. The individual will sit in a chair facing the slit lamp with their chin and
forehead resting on a support. The doctor can use this instrument to observe the eyes
in detail and determine whether or not there are any abnormalities. Through it,
conjunctiva, cornea, eyelids, iris, pupil, lens, sclera, retina, etc. can be visualised.
Procedure
After an initial look at the eyes, a special dye called fluorescein can be applied to eyes
to make the exam easier. This dye can be administered as an eye drop or on a small,
thin paper strip that touches the white of the eye.
Then a series of eye drops can be administered that will dilate the pupils. The dilation
will make it easier to see the other structures in the eye. It takes about 20 minutes for
the drops to work.

Fig. Slit lamp examination

 Tonometry- Tonometry is the procedure used to determine the intraocular pressure

(IOP), the fluid pressure inside the eye. It is an important test in the evaluation of
patients at risk from glaucoma.

Fig. Tonometry

 Color vision testing- A color vision test, also known as the Ishihara color test,
measures the ability to tell the difference among colors. If someone doesn’t pass this
test, they may have poor color vision, or are colour blind. It is a widely used test for
color blindness that consists of a set of plates covered with colored dots which the test
subject views in order to find a number composed of dots of one color which a person
with various defects of color vision will confuse with surrounding dots of color.
 Fig. Ishihara chart

 Amsler grid- The Amsler grid is a grid of horizontal and vertical lines used to monitor
a person's central visual field. It is a diagnostic tool that aids in the detection of visual
disturbances caused by changes in the retina, particularly the macula (e.g. macular
degeneration), as well as the optic nerve and the visual pathway to the brain.
In the test, the person looks with each eye separately at the small dot in the center of
the grid. Patients with macular disease may see wavy lines or some lines may be
missing. The original Amsler grid was black and white. A colour version with a blue
and yellow grid is more sensitive and can be used to test for a wide variety of visual
pathway abnormalities, including those associated with the retina, the optic nerve, and
the pituitary gland.

Fig. (A) Person with normal vision; (B) Person with visual disturbance

 Ultrasonography-Ocular ultrasound, also known as ocular echography, "echo," or a B-

scan, is a quick, non-invasive test routinely used to assess the structural integrity and
pathology of the eye in clinical practice.
Procedure- The eyes are numbed with medicine (anaesthetic drops). The ultrasound
wand (transducer) is placed against the front surface of the eye. The ultrasound uses
high-frequency sound waves that travel through the eye. Reflections (echoes) of the
sound waves form a picture of the structure of the eye. The test takes about 15
minutes.

Fig. Ultrasonography of eye

 Optical coherence tomography- Optical Coherence Tomography (OCT) is a non-

invasive diagnostic instrument used for imaging the retina. With an OCT, we can see
a cross section or 3D image of the retina and detect the early onset of a variety of eye
conditions and eye diseases such as macular degeneration, glaucoma and diabetic
retinopathy (the top three diseases known to cause blindness).
The OCT allows for detection of other diseases such as macular holes, hypertensive
retinopathy and even optic nerve damage. The OCT uses an array of light to rapidly
scan the eye. These scans are interpreted and the OCT then presents an image of the
tissue layers within the retina.
 Fig. Optical coherence tomography

 Fundus photography- Fundus photography involves photographing the rear of an eye;

also known as the fundus. Specialized fundus cameras consisting of an intricate
microscope attached to a flash enabled camera are used in fundus photography. The
main structures that can be visualized on a fundus photo are the central and peripheral
retina, optic disc and macula. Fundus photography can be performed with coloured
filters, or with specialized dyes including fluorescein and indocyanine green.

Fig. Fundus photography

 Laser scanning- It is a method used to image the retina with a high degree of spatial
sensitivity. It is helpful in the diagnosis of glaucoma, macular degeneration, and other
retinal disorders. It has further been combined with adaptive optics technology to
provide sharper images of the retina.

Fig. Laser scanning of eye

 Angiography- An eye angiogram uses fluorescein dye and a camera to take pictures
and evaluate the blood flow through the vessels in the back of the eye
During an eye angiogram, the dye is injected into a vein in your arm. Once injected, it
takes about 10 to 15 seconds to circulate through your body. As the dye enters the
blood vessels in your eyes, a series of photos are taken to chart the dye's progress.
More pictures are taken after most of the dye has passed through your eyes to see if
any of it has leaked out of the blood vessels. Any dye that leaks out of the blood
vessels will color the tissues and fluid in the eye. Filters in the camera allow the areas
colored by the dye to show up in the photos.
 Fig. Angiography of eye

 Perimetry testing- A perimetry test (visual field test) measures all areas of your
eyesight, including your side, or peripheral, vision.
In this test, the patient has to sit and look inside a bowl-shaped instrument called a
perimeter. While the patient stare at the centre of the bowl, lights flash. The patient
press a button each time he see a flash. A computer records the spot of each flash and
if the patient pressed the button when the light flashed in that spot.
At the end of the test, a printout shows if there are areas of patient’s vision where he
did not see the flashes of light. These are areas of vision loss. Loss of peripheral
vision is often an early sign of glaucoma.

Fig. Perimetry

RESEARCH ARTICLES
1. Knowledge and practice patterns of Intensive Care Unit nurses towards eye care
in Chhattisgarh state
A study was conducted by Sonal Vyas, Ashish Mahobia, and Sangeeta Bawankure to
present the level of knowledge and practice patterns regarding exposure
keratopathy in mechanically ventilated patients among Intensive Care Unit (ICU)
nurses in Chhattisgarh state. A previously validated semi-structured questionnaire was
administered in the ICU of six multispecialty hospitals in Chhattisgarh in 2014–2015.
Most of the questions dealt with frequency of eyelid closure assessment, frequency of
cleaning of eyes with saline gauze, using a protocol-based approach for eye care, and
documentation of ophthalmic complications. Common barriers to delivery of eye care
such as shortage of time and too much writing tasks were also inquired. This study
included 120 nurses. Knowledge about high risk of exposure keratopathy in
ventilated patient was present in 93% nurses. Only six nurses (5%) followed a strict
protocol for eye care, 52 nurses (43%) checked for eyelid closure in the ventilated
patients, and 58 (48%) cleaned the eyes frequently. Nurses in cardiac ICU were
significantly lesser aware of exposure complications compared to medical ICU
nurses. The study concluded that although there is high awareness, practice
patterns of ICU nurses were less than desired. Educational initiatives should focus
on weaknesses in knowledge and practice noted to improve eye care of patients in
ICU.4
2. A study on knowledge regarding eye donation among first year nursing students
of a nursing school and college of Berhampur, Odisha
A cross-sectional study was conducted in May 2016 with 140 first year Nursing
students to assess their perception towards eye donation. All participants knew about
eye donation and 95.7% said these can be done irrespective of age and sex of the
deceased. 55% students told HIV is a contraindication,10% said that request for eye
donations can be made by person himself alive or relatives after death. 15% knew that
eye can be donated within six hours of death but none were aware regarding storage
of donated eyes before transplantation. Only 2.1% of them heard about Hospital
Corneal Retrieval Programme. Television (100%) was the main source of
 information. All of them personally supported eye donation. The study concluded
that nursing students had heard about eye donation but knew less about the
details of the procedure. They can contribute to awareness and motivating
people for eye donation during their postings in various department in hospital.5
SUMMARY AND CONCLUSION
 As discussed throughout the presentation, learning about eye examination will help
the nurses to care better for patients.
 Nurses can do eye assessment, classify the level of disease, observe the sign and
symptoms, provide the necessary nursing care and support the patient
psychologically.
REFERENCES
1. Janice L. Hinkle, Kerry H. Cheever. Brunner and Suddarth’s Textbook of Medical
Surgical Nursing. 2015. New Delhi. Wolters Kluwer.13th Edition. Volume 2. Pg. no.
1839-1846.
2. Lewis. Medical Surgical Nursing Assessment and Management of clinical
problems.2015. New Delhi. Elsevier. 2nd Edition. Volume II. Pg. no. 382-392.
3. Joyce M. Black, Jane Hokanson Hawks. Medical Surgical Nursing Clinical
Management of Positive Outcomes.2015. New Delhi. Reed Elsevier India Private
Limited. Volume II. Pg. no. 1677-1686
4. PubMed. Knowledge and practice patterns of Intensive Care Unit nurses towards eye
care in Chhattisgarh state. Available from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113811/ [cited 21 Nov 2019]
5. IJRMS. A study on knowledge regarding eye donation among first year nursing
students of a nursing school and college of Berhampur, Odisha. Available from
https://www.msjonline.org/index.php/ijrms/article/view/3984 [cited 21 Nov 2019]